Introduction: Bronchial asthma is a highly prevalent disease, and in most of the etiopathogenesis and symptomatology, it can be correlated with Tamaka Shvasa. Ikshvaku (Lagenaria vulgaris [Manila] Standley.) is an annual herbaceous climbing plant with a long history of medicinal uses for the treatment of various ailments including jaundice, diabetes, ulcer, piles, colitis, asthma, insanity, hypertension, congestive cardiac failure and skin disorders. Its fruit pulp is used both as an emetic and as a purgative. Aims: To study the efficacy of Vamana Karma with Ikshvaku (Lagenaria vulgaris [Manila] Standley) Ksheera Yoga. Materials and Methods: A total of 15 patients fulfilling the diagnostic criteria for bronchial asthma were selected from outpatient and inpatient department of Panchakarma Department. The sign and symptoms, mainly breathlessness, cough and rhonchi were given scores depending on their severity. The patients were also assessed for lung function test to determine pulmonary impairment. For Vamana, they were given Deepana and Pachana with Trikatu Churna for 3 days and then they were subjected to Snehapana with lukewarm cow's ghee. After the completion of Snehapana, the patient were given Abhyanga, Vashpa Swedana and diet with predominance of Kapha (Kapha Bahula Ahara- diet mixed with milk or curd), which was then followed by Vamana with Ikshvaku Ksheera Yoga and Samsarjana Krama. Follow-up was done at an interval of 15 days for three times and t scores were noted before and after the treatment. The scores were analyzed using Wilcoxon signed-rank test for subjective parameters and Student's paired t- test for objective parameters. Results: The trial drug has shown statistically highly significant reduction in breathlessness, cough, rhonchi, and significant changes in lung function tests. Conclusion: The test drug proved its emetic effect on the patients of bronchial asthma and thus relieved the symptoms of the disease immediately. It has reduced frequency of episodes of breathlessness and severity of symptoms.

Keywords: Asthma, Ikshvaku, Tamaka Shvasa, Vamana

How to cite this article:Patil SG, Thakar AB. Efficacy of Vamana Karma with Ikshvaku Ksheera Yoga in the management of Tamaka Shvasa (bronchial asthma). AYU 2017;38:10-4

The word Tamaka Shvasa is derived from the word Tama, the meaning of “Tama” is oppression of chest [1] which is similar to bronchoconstriction felt by the patients of asthma due to sensation arising from resistive airways. Asthma is a chronic inflammatory disorder of airway hyper responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or early in the morning. The prevalence of self-reported asthma was 1.8% among men and 1.9% among women.[2] Females, high body mass index, low body mass index, advancing age, residence in urban area, lower socioeconomic status, rapid industrialization, increased population, increase in air pollution, and all forms of tobacco smoking increase the risk of asthma.[3]

Faulty food habits lead to Agnimandya and responsible for Annavaha Srotodushti which is the basic cause for the initiation of Samprapti, as Mulasthana of Tamaka Shvasa is Pittasthana. Modern science also accepts the role of diet in bronchial asthma as diets low in antioxidants and some foods, such as shellfish and nuts, may induce anaphylactic reaction are associated with an increased risk of asthma.[4]Viharaja Nidanas are mainly Vata Prakopaka and Pranavaha Srotodushtikara. Raja, Dhuma etc. are indicating toward the allergens; seasonal changes also can be considered as aggravating factors in the manifestation of disease.

The disease is originated from Pittasthana and situated in Kapha Sthana characterized by dominant features of vitiated Kapha along with obstruction to movement of Vata causing Vata Prakopa and breathlessness.[5] Considering the above fact in the pathogenesis of Tamaka Shvasa, it may be assumed that Vamana Karma is most suitable therapeutic procedure for the disease and Ikshvaku has anti-allergic, anti-inflammatory, emetic, and Rasayana properties. Therefore, to evaluate its Vamaka effect on bronchial asthma, the present study was carried out.

Materials and Methods

The study was conducted on the patients who reported in the outpatient and inpatient department of Panchakarma, IPGT and RA, GAU, Jamnagar, for the treatment of bronchial asthma.

A total of 15 patients of Tamaka Shvasa (bronchial asthma) of both the sex having age in between 16 and 55 years with disease chronicity up to 10 years were selected for the study.

The study design was approved by the Institutional Ethics Committee vide its letter no. PGT/A/Ethics/201112/2687. Dt. 05/09/2011 and was also registered in clinical trial [CTRI/2014/01/004330] registry of India. Written informed consent was obtained from each patient before including them in the trial.

Before conducting clinical trial for quality control of Ikshvaku (Lagenaria vulgaris [Manila] Standley) fruits were collected from the local farms of Chandrapur district, Maharashtra in December–January. The fresh and semi-ripped fruits were cut into small pieces. The pulp obtained from fruits were shade dried and made into the coarse powder and later its pharmacognostical, physicochemical, and phytochemical evaluation was carried out at IPGT and RA, GAU, Jamnagar [Table 1] and [Table 2].

All the registered patients who met inclusion criteria and gave consent for the Vamana were administered Trikatu Churna[6] for the first 3 days for Deepana and Pachana[7] in the dose of 3 g thrice a day with lukewarm water after meal. On the 4th day, after assessing the status of the patients, nonmedicated ghee in the dose of 30 ml was given in the early morning on an empty stomach with lukewarm water. The patients were observed for Sneha Jeerna Lakshana and accordingly for the next 5–7 days; the dose of ghee was given in increased pattern till the patients achieved proper Snehana features (Samyaka Snigdha Lakshana).[8] After completion of Snehapana, whole-body massage and fomentation with Bala Taila and Vashpa Swedana was done for 1 day at morning and evening according to strength of the patient. A night before Vamana, the patients were given Kapha Bahula diet such as curd, milk, and sugarcane juice. On the day of planned Vamana procedure in the morning after Abhyanga and Bashpa Swedana, patients were given milk to drink up to their satisfaction. Thereafter, Vamana with Ikshvaku Ksheera Yoga was given.

Method of preparation of Ikshvaku Ksheera Yoga

For the preparation of Ikshvaku Ksheera Yoga 2 g (each) coarse powder of Vacha, Pippali, and Saindhava lavana was added in 4 g of Ikshvaku Churna. It was then mixed 20 g with honey and 60 ml milk to make the formulation (Yoga) more palatable.[9]

Thereafter, according to the type of Shuddhi, at the end of Vamana procedure, 3, 5, and 7 days, dietary regimen was advised which included Peya, Vilepi, Akrita Yusha, and Krita Yusha in a sequential pattern.[10]

After completion of Vamana, patients were asked to report after 15 days to record the details regarding the status.

Criteria for assessment

Subjective parameters presented by the patients were given score and were assessed before and after performing Vamana Karma.

Gradation for Subjective parameters:

Shvasakashtata

The MRC breathlessness scale was adopted for Shvasa Kashtata.

Not trouble with breathlessness except on strenuous exercise-1

Short of breaths when hurrying on the level or walking up a slight hill-2

Walks slower than most people on the level, stops after a mile or so or stops after 15 min walking at own pace-3

Stops for breath after walking about 100 yards or after a few minute on level ground-4

Too breathlessness to leave the house or breathlessness when undressing-5.

Kasa (cough) duration/severity

No cough- 0

Occ. cough- 1

1–2 time/day- 2

2–5 time/day- 3

Throughout day- 4

Throughout day and night- 5

Rhonchi

No rhonchi- 0

Localized (inspiration/expiration)- 1

Scattered unilateral (inspiration/expiration)- 2

Scattered bilateral (inspiration/expiration)- 3

Generalized rhonchi (inspiration/expiration)- 4

High pitched unilateral (inspiration/expiration)-5

High pitched bilateral (inspiration/expiration)- 6

Objective parameters

Improvement in lung function tests mainly peak expiratory flow rate and forced expiratory volume (FEV) was observed. Changes in hematological parameters mainly ESR and AEC were also considered for assessment, and they were assessed in comparison to the baseline score.

Statistical analysis

General data were subjected to suitable statistical analysis such as descriptive statistics for demographic data, Wilcoxon signed-rank test for nonparametric paired data and paired t-test for quantitative parametric paired data. After preparing the master chart of all the required data in Microsoft Excel worksheet, statistical calculations were made with the help of SigmaStat 3.5 software, San Jose, California and InStat 3 software, La Jolla, USA. The results were interpreted as significant (P< 0.05), highly significant (P< 0.01), and insignificant (P > 0.05).

Observations

A total of 15 patients have registered in the study, and out of them, 13 patients completed the treatment. Two patients dropped out due to migration. The demographic data show that 73.34% patients were females, 80% belonged to age group of 26–45 years, 66.67% patients were homemakers, and 80% were laborers. Regarding Prakriti, 53.33% were of Kapha-Vata dominant Prakriti. Madhyama Koshtha was found in 46.67% of patients followed by 33.33% patients having Mridu Koshtha.

Disease chronicity of asthma up to 10 years was found in 33.33% of patients, positive family history of asthma was found in 40% of patients and history of frequent cold was found in 60% of patients while rhinitis in 53.33% of patients. Frequent use of inhalers (beta-agonists) was seen in 73.33% of patients followed by steroids in 46.67% of patients. Ingestion of Amla Madhura Rasa dominant Aahara was noticed by 66.67% of patients followed by 73.33% of patients taking Snigdha Guna dominant. Diet ingestion of curd (Dadhi Sevana) was observed in 66.67% of patients while fermented food was taken by 60% of patients; irregular times of food was noted in 60% of patients and Viruddhahara was noted in 80% of patients.

Early morning breathlessness was observed in most of the patients, followed by dry cough and productive cough in 40% of patients. Rhonchi was observed in 86.67% of patients and crepitations in 73.33% of patients. In 66.67% of patients, dust, pollens, and day sleep was observed as aggravating factors and extreme cold in 80% of patients. Relief in breathlessness after sitting position was observed in 53.33% of patients.

Observations of Vamana Karma

Time of induction of first Vega during Vamana Karma is 28.60 min (average); it shows that Ikshvaku Ksheer Yoga takes more time for induction of first Vega. After giving Vamana Yoga, self-induced Vega were observed in 66.67% of patients and projectile Vega were observed in 46.66% of patients while Pittanta Vega were observed in 73.33% of patients. Average number of Vega were 5.93. Average number of Upavega were 7.06, indicating that the patients have Madhyama to Pravara Shuddhi and no complications were observed during Vamana[Table 3].

It has been established that in all the patients of asthma, dyspnea is due to mechanical interference in ventilation because of airway obstruction. It affects the rate and pattern of breathing. In 60% of patients, asthma attack was observed in early morning, which may be due to early morning fall in circulating adrenaline and decreased plasma cortisol concentration.[11] In 86% of patients, wheezing may have resulted from localized or diffuse airway narrowing or obstruction caused by bronchoconstriction, mucosal edema, and tenacious secretions; coughing may be due to airway inflammation and hypersensitivity to the allergens. Fifty-three percent of patients reported relief in sitting position because in sitting position diaphragm is lowered and secretion of airways will not obstruct the airways completely.

Maximum number of patients had habit of Vishtambhi (less fiber foods), Vishama Aahara (irregular food habits), Diwasvapna (day time sleeping) and Ratrijagarana (night awaking) which leads to improper digestion, Aama production, and initiates the disease process. In the present study, 53.33% of patients were having Kapha Vata Prakruti because these persons are more prone to asthmatic attack due to vitiation of Kapha and Vata which are main causative factors of disease which occurs instantaneously due to dominant Dosha.[12]

In the present study for Vamana Karma instead of using the classical Madanphala Yoga, Ikshvaku Ksheera Yoga was selected due to its good expectorant, emetic, anti-allergic, anti-inflammatory, and Rasayana properties. For Vamana Karma the average dose of Ikshvaku Churna is 4 g and average dose of total Vamana Yoga was 27 g. This indicates that the Utklesha of Dosha was good and Ikshvaku Ksheer Yoga is extremely bitter, expectorant, and potent enough to induce projectile and self-induced Vegas, particularly in the patients of Tamaka Shvasa, and this may be one of the reasons for using formulation specific to the disease.

In objective parameters, it was found that AEC was reduced by 22.31% as earlier researches showed Vamana Karma reduces histamine level in the body.[13] Peak expiratory flow and FEV1% was increased after Vamana because of the removal of occluded mucous and reduced airway obstruction.

Probable mode of action of Vamana with Ikshvaku Ksheera Yoga

Trikatu Churna was given as Deepana–Pachana before Abhyantara Snehapana because its inherent properties such as Aampachana and Agnideepana. Aampachana also helps to reduce Pichhilata of morbid matter so that they can be easily dislodged. Snehapana increases the fluidity and moistness in the body and makes the body soft and unctuous; it helps in dislodging the harmful substances from the tissues.

Though there is no classical reference to add other Dravya except milk in the Ikshvaku Ksheera Yoga, it was mixed with Saindhava, Pippali, and Madhu as it works on both Kapha and Vata Dosha to prevent the Vata aggravation and to facilitate easy expulsion of Kapha. Due to Samshodhana (Radical cure), Bhedaka (penetration) and Kaphanissaraka properties of Ikshvaku vitiated and stagnant, Kapha may get expelled out from the system and thus clears the channels of circulation, resulting in movement of Vayu without any obstruction and ultimately the patient get relief after removal of vitiated Kapha. Hence, Ikshvaku Ksheera Yoga seems to be more suitable for Vamana Karma in the Tamaka Shvasa.

Conclusion

The result suggested that Ikshvaku Ksheera Yoga is safe, efficacious, and best emetic formulation for bronchial asthma due to its Samshodhana, Bhedaka, and Kaphanissaraka properties. Its clinical efficacy on bronchial asthma also suggested that the Ikshvaku Ksheera Yoga is extremely potent emetic drug to induce self, projectile Vega which relieves the symptoms of the disease immediately and it also provides prevention by reducing frequency and severity of symptoms of Tamaka Shvasa for longer duration. Hence, it can be said that Ikshvaku Ksheera Yoga can be used as disease-specific emetic formulation for bronchial asthma and best alternative to routine Vamaka Yogas in future.